controlled document - uhb

Guidelines for the Care of Patients Requiring Enteral Feeding Document control number: CG198 Version 5.4 of 81

Guidelines for the Care of Patients Requiring Enteral Feeding

CATEGORY: Guideline CLASSIFICATION: Clinical PURPOSE To enable all staff caring for patients

receiving enteral feeding to do so safely and effectively using evidence based practice and in accordance with national guidance.

Controlled Document Number:

CG198 Previously 191 *amendment May 2016 and June 2020

Version Number: 5.4 Controlled Document Sponsor:

Chief Nurse

Controlled Document Lead:

Lead Nurse for Nutrition

Approved By: Clinical Guidelines Group On: July 2015 Review Date: May 2021 Distribution: Essential Reading

for Information for:

Registered Nurses, Medical Staff and Dietitians. All staff involved with enteral feeding.

Version Guideline Amendments

5.4 Guidelines for the Care of a Patient Receiving Nasojejunal feeding has been removed and is now a stand alone procedure: Procedure for the Management of Naso jejunal Feeding Tubes and Insertion of Self-propelling Naso jejunal Feeding Tubes in Adult Patients CG1166

5.3 Guidelines for the Care of a Patient Receiving Nasogastric

feeding has been removed and is now a stand alone procedure: Procedure For The Insertion And Management Of Fine Bore Nasogastric Feeding Tubes in Adult Patients

.

CO

NTR

OLL

ED D

OC

UM

ENT


ENTERAL FEEDING GUIDELINES Contents

Page

Part 1: Guidelines for the Care of Patients Receiving Enteral Tube Feeds

3

Part 2: Guidelines for Bolus Feeding via an Enteral Feeding Tube

12

Part 3:

Guidelines for the Care of a Patient Feeding via a Percutaneous Endoscopic Gastrostomy (PEG)

18

Part 4:

Guidelines for the Care of a Patient Feeding via a Radiologically Inserted Gastrostomy (RIG).

30

Part 5: Guidelines for the Care of a Patient Feeding via a Balloon Retained Gastrostomy Tube

42

Part 6: Part 7:

Guidelines for the Care of a Patient Feeding via a Surgical Jejunostomy Guidelines for the Administration of Drugs in Accordance with UHB Medicines Policy and Procedure.

49

57

Part 8: Part 9:

Guidelines for Trouble Shooting Problems Associated with Enteral Feeding Tubes Guidelines for caring for a patient with an AMT nasal loop/bridle or nasal sloop

64

71

Part 10: Guidelines Submission Details 81


PART 1

GUIDELINES FOR THE CARE OF PATIENTS RECEIVING ENTERAL TUBE FEEDS


CONTENTS

PAGE

Section 1:

Introduction 5

Section 2:

Routes of Feeding 5

Section 3:

Methods of Feeding 5

Section 4:

Equipment 5

Section 5:

Patient Position 6

Section 6: Section 7:

Potential Complications Discharging Patients on Enteral Tube Feeds

6

6

References/Bibliography

8

Appendices

Appendix 1 Care of Patients Receiving Enteral Tube Feeding

9

Appendix 2 Discharge Checklist 11


1. Introduction

1.1 Whenever possible a patient’s nutritional requirements should be met by eating and drinking. The standard hospital diet can be supplemented at source with additional calories and protein. Sip feeds may also be used. However, on some occasions the patient may still be unable to meet their nutritional requirements. Enteral tube feeding might then be considered. (see Appendix 1 for the procedure for the care of patients receiving enteral tube feeding).

1.2 Tube feeding can be:

Total – providing all of the patient’s nutritional requirements Supplementary – being a ‘top up’ for those unable to take sufficient

orally or for those being weaned from parenteral nutrition

2. Routes of Feeding 2.1 Different routes of tube feeding are possible, the choice being

determined by:

Level of access to gut possible due to underlying condition Expected duration of feeding Patient choice

2.2 Possible routes include:

Nasogastric Naso-duodenal/jejunal Gastrostomy Jejunostomy

3. Methods of Feeding

3.1 The following methods of feeding may be considered:

Continuous Continuous, cyclical Bolus

3.2 In hospital most enteral feeds are given using an enteral feeding pump

either: Continuously (over 24 hours) or Continuously cyclically (over 18-20 hours) or Overnight (10-15 hours).

4 Equipment

4.1 Enteral feeding pumps are used for continuous and continuous/cyclical feeding.


4.1.1 All members of staff using these pumps must have received adequate training in accordance with Trust Procedure for Managements of Medical Devices (current version) .

4.2 The appropriate giving set for the pump must be used. It is unsafe to

use any other type of giving set with these pumps. 4.3 A direct access foil penetrating spike/ screw set must be used for

sterile pre-packed feeds in collapsible pack or rigid plastic presentation.

The collapsible pack presentations carry the least risk of feed contamination (Beattie & Anderton 1998, 1999).

If decanting is unavoidable (e.g. feed needs to be mixed from

powders or the appropriate feed is presented only in a bottle or carton), an enteral reservoir bag or bottle and set may be used.

4.4 Only 50-60ml purple enteral syringes (as they are not compatible with

intravenous and other parenteral devices) must be used for flushing/ bolus feeding via enteral feeding tubes. Syringes designed for administering medicines/ flushes via parenteral routes (e.g. intravenous) must not be used. Larger sizes of enteral syringe (i.e. 50-60ml) are used as they are less likely to cause excess pressure within the enteral feeding tube than smaller sizes of syringe.

5. Patient Position

5.1 During the administration of feeds, and for approximately an hour after,

whenever possible patients should have their head and shoulders supported at a 45° angle (approximately the height of two pillows). This will help to reduce the risk of reflux and aspiration of feed.

5.2 Patients should not receive feed whilst lying flat, unless sitting at a 45°

angle is clinically contra-indicated. 6. Potential Complications

Vomiting Diarrhoea Tube displacement (Refer to Part 9: Trouble shooting, Problem 4;

displaced tube) 7. Discharging Patients on Enteral tube feeds

Some patients will be discharged home or to a nursing home or other care facility with an enteral feed. To ensure a safe discharge is it imperative that: Where appropriate patients/carers have received adequate training

to allow them to care for their tube and administer their feed safely. Where appropriate patients/carers have received written information

regarding caring for their tube and administering their feed.


The patient/carers have been given contact telephone numbers should they encounter any problems with their feed or tube.

Patients are given the correct items on discharge. See Appendix 2 for the Discharge Checklist for patients being discharged home on enteral feeds. This check list must be printed off and each action signed by the ward staff once there is documented evidence it is completed. This must then be filed in the patient's medical records.


REFERENCES/ BIBLIOGRAPHY Anderton A, (1999) Enteral tube feeds is a source of infection: can we reduce the risk? Nutrition 15: 55-57 A.S.P.E.N. Enteral Nutrition Practice Recommendations (2009) Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J and the A.S.P.E.N. Board of Directors. JPEN J Parenter Enteral Nutr MARCH-APRIL 2009 vol. 33 no. 2 122-167 Beattie T, Anderton A, (1998) Bacterial contamination of enteral feeding systems due to faulty handling procedures: a comparison of a new system with two established systems. Journal of Human Nutrition & Dietetics 11: 313-321 Beattie T, Anderton A, (1998) Microbiological evaluation of four enteral feeding systems which have been deliberately subjected to faulty handling procedures. Journal of Hospital Infection 42: 11-20 Crest (2004) Guidelines for the Management of Enteral Tube Feeding in Adults. Clinical Resource Efficiency Support Team. April 2004 Department of Health (2006) Essential Steps to Safe Clean Care: Preventing the Spread of Infection. Crown Copyright. ICNA (2003) Enteral Feeding: Infection Control Guidelines. Infection Control Nurses Association. June 2003 Medical Devices Agency (2000) Single Use Medical Devices: Implications and Consequences of Re-use. MDA, DB2000(04) NICE (2012) CG 139 - Infection: Prevention and control of healthcare-associated infections in primary and community care. National Institute for Clinical Excellence. University Hospitals Birmingham NHS Foundation Trust Procedure for Managements of Medical Devices (current version) University Hospitals Birmingham NHS Foundation Trust

Appendix 1


CARE OF PATIENTS RECEIVING ENTERAL TUBE FEEDING

ACTION

RATIONALE

1. Refer to prescription supplied by dietitian on PICS and check: route/ method type of feed rate of feed

Patient receives correct feed at correct rate via correct route

2. Contact dietitian if no prescription available

All patients have their nutritional requirements calculated by a dietitian to ensure optimum nutritional support

3. If unable to contact dietitian: Medical staff to review fluid

balance and prescribe: Nutrison

30ml/hr x 24 hours via an enteral feeding pump and contact dietitian as soon as possible.

NB: RENAL PATIENTS dietetic/ medical advice must always be sought before commencing enteral feed

Provision of nutrition within safe limits. Renal patients may have strict fluid and/or dietary restrictions.

4. Decontaminate hands with liquid soap and water, and dry thoroughly prior to assembling enteral feed components.

Work in clean area. Use minimal handling and an

aseptic non touch technique to connect the administration system to the enteral feeding tube

To reduce possibility of contaminating feed (Department of Health 2006, ICNA 2003) NICE 2012

5. If decanting sterile feed (cans, cartons of supplements) into a reservoir bag/bottle Wear clean gloves and

decant sufficient for 24 hours if possible.

Clean tops of cans with alcohol wipe before decanting

Cleaning with alcohol reduces risk of contamination (Anderton 1998)


ACTION

RATIONALE

5. cont

Avoid ‘topping up’ of reservoir

If feed is to be mixed from powder (Elemental 028), use sterile water and make/hang sufficient for 4 hours only

Topping up of feed increases risk of contamination (Patchell 1994, 1998, CREST 2004) Mixing from powder has the highest risk of contamination. Prolonged hanging times increase risk of microbiological growth (NICE 2003)

6. Change all giving sets after 24 hours

Use 50-60 ml purple enteral

syringes once and discard

Feeding systems in use for longer than 24 hours show raised bacterial counts (ASPEN 2009, ICNA 2003) Syringes and most giving sets are ‘single use only’ items (MDA 2000)Larger sizes of enteral syringe (i.e. 50-60ml) are used as they are less likely to cause excess pressure within the enteral feeding tube than smaller sizes of syringe.

7. Do not use connectors/ ’3 way taps’ on enteral feeding tubes

Each additional connector increases risk of contamination (ICNA 2003). The use of a ‘3 way tap’ makes system compatible with Intravenous (IV) giving sets and increases the risk of inadvertent infusion of enteral product via an iv line.

8. Weigh the patient on admission and again weekly and complete Nutrition Screening Tool (MUST)

To determine progress and adequacy of feed being given

9. If the patient is nil by mouth provide/encourage regular mouth care(see Trust Oral Hygiene guidelines , current version).

To promote good oral hygiene and early identification of oral infections

10. Encourage a positive attitude to tube feeding by providing information, support and advice to patient/carer Patient information booklets are available from the print room and on the intranet. See specific sections for print codes or Contact the Nutrition Nurses Or Dietitians for more details.

Anxieties of patient/carer are reduced

11. Record all feed given on fluid balance chart.

To maintain an accurate record of the patient’s fluid balance


Appendix 2 ENTERAL FEEDING DISCHARGE CHECKLIST

QUESTION

Responsibility Rationale Initial when complete

1 Has the patient been reviewed by the Dietitian?

Dietitian Dietitian must devise feeding regimen and register patients with the homecare company

2 Is the patient aware they are going home with Enteral Feeding?

Ward staff/ dietitian

Discharge planning

3 Have the discharge plans been discussed with the patient’s carer/ Next Of Kin?

Ward staff/dietitian

Discharge planning

4 Has the patient received written information about Home Enteral Feeding and tube care?

Nutrition Nurses/

Homecare company Nurse

Ensure patient fully informed

6 Has the patient been shown how to care for their tube?

Nutrition Nurses/

Homecare company Nurse/

ward staff

Ensure safe discharge. Note: normally done by Nutrition nurses or the

homecare company nurse. However, ward staff may also

need to train patients.

7 Has the patient received training on how to use the pump where appropriate?

Homecare company nurse

Ensure safe discharge

8 Does the patient have all the relevant literature including contact numbers?

ALL Ensure patient is aware of who to contact in case of problems

9 Has the Homecare company nurse supplied the pump and stand?

Homecare company nurse

Has access to equipment in the dietetics dept.

10 Has a 10 day supply of feeds been given to the patient? 14 day supply on a Bank Holiday)

Ward staff To be supplied by the ward until home delivery arranged

11 Has the patient been given a 10 day supply of giving sets and syringes? (14 days’ supply on a Bank Holiday)

Ward staff To be supplied from ward stocks until home delivery

arranged

12 NG Tubes: Has the patient been supplied with pH paper and spare NG tube?

Ward staff Patient to have spare tube in case of problems and pH

paper to check tube position

13 Have arrangements for tube replacement been made if the patient has a problem e.g. to return to the ward or go to A&E?

Ward staff Tube displacement is common in NG fed patients. There can

be problems with trying to insert tubes in the community. The patient must be aware of

who to contact if there are problems.

14 Discharge within 72 hours of new PEG or RIG: Has the patient received information about potential post procedure complications?

Nutrition Nurses Essential that the patient knows which symptoms to

observe for and what action to take

15 Has the patient been given follow up information?

All Patient to be aware of arrangements for follow up e.g. with dietitian, nutrition nurses or homecare company nurse.

16 Handover -if the patient is going into a care facility or having district nursing input has handover been given as above.

All Community team must be aware of aftercare instructions and follow up arrangements


PART 2

GUIDELINES FOR BOLUS FEEDING VIA AN ENTERAL FEEDING TUBE


CONTENTS

PAGE

Section 1: Introduction

14

Section 2: Advantages/ Disadvantages of Bolus Feeding

14

Section 3: Syringes

14

Section 4:

Site of Delivery 14


16

Appendices Appendix 1 Procedure for Bolus

Feeding via an Enteral Feeding Tube

17


1. Introduction 1.1 There are a variety of methods for delivering feed via enteral feeding

tubes. They include: Continuous/ intermittent feeding via pump Intermittent bolus feeding.

1.2 Some enteral feeding pumps are able to deliver bolus feeds; however, the term ‘bolus feeding’ generally refers to the method of giving a volume of feed (e.g. 200mls) with a syringe. (See Appendix 1 for procedure for bolus feeding via an enteral feeding tube)

1.3 Careful consideration must be given before commencing a patient on

bolus feeding as it is known to cause problems with regurgitation and diarrhoea (Stroud et al 2003).

1.4 Often patients in their own homes, and those who have good dexterity

or support, are most suited to bolus feeding. 2. Advantages/ Disadvantages of Bolus Feeding 2.1 Advantages:

More physiologically normal than continuous feeding (normal meal patterns can be maintained)

Patient is not restricted by a feeding pump/equipment (allows mobility)

May be suitable for patients who are mildly confused or at risk of pulling at giving set tubing

2.2 Disadvantages:

Very time consuming and may be accidentally forgotten in the hospital/care setting (Payne-James et al 2001)

May not be able to give patients nutritional requirements within bolus feeding range

May not be suitable for patients with slower gastric emptying e.g. some patients with neurological disorders (Rhoney et al 2002)

3. Syringes 3.1 A 50-60ml purple enteral syringe must be used to give bolus feeds as

smaller syringes may increase the internal pressure on the feeding tube. Syringes used for enteral feeding must be non-IV compatible.

3.2 Syringes are for single use only. 4. Site of Delivery 4.1 Bolus feeding into the jejunum is not recommended as rapid infusion

may lead to a ‘dumping’ type syndrome (Stroud 2003).


4.2 However, if this method of feeding is unavoidable or preferable then

extra care must be taken with the infusion rate.


REFERENCES/ BIBLIOGRAPHY Garrow J., James W. & Ralph A. (2001) Human Nutrition and Dietetics. 10th edition. Churchill Livingstone. Pg. Guenter P. & Silkroski M. (2001) Tube Feeding: Practical Guidelines and Nursing Protocols. ASPEN Publishers, Maryland, USA pgs. 82-83 Payne-James J., Grimble G. & Silk D. (2001) Artificial Nutrition Support in Clinical Practice. 2nd edition. Greenwich Medical Media Ltd. London. Pg. 295 Rhoney D, Parker D., Formea C., Yap C, & Coplin W. (2002) Tolerability of bolus versus continuous gastric feeding in brain-injured patients. Neurological Research Volume 24, Issue 6 (01 September 2002), pp. 613-620 Stroud M., Duncan H. & Nightingale J. (2003) Guidelines for Enteral Feeding in Adult Hospital Patients. GUT. December 2003, vol 52


Appendix 1

PROCEDURE FOR BOLUS FEEDING VIA AN ENTERAL FEEDING TUBE

ACTION

RATIONALE

1.

Positioning: Patient must be well

supported in the upright position (or at a minimum of 45 degrees) for feeding and for an hour after feed

To minimise the risk of

regurgitation and aspiration during feed administration.

2.

Administering Feed: Use a 50ml purple enteral

syringe to flush the feeding tube with approx. 30mls water (or per feeding regime)

Administer the prescribed

quantity of feed, using gentle pressure on the plunger.

A rate of approximately

50ml over 2-3 minutes should be aimed for. e.g. 240mls feed should take minimum 10 mins, (Guenter & Silkroski 2001)

When the full amount of feed

has been delivered a further 30ml water flush should be given (or as per regimen)

To check tube patency prior to

feeding and deliver fluids according to regime. Smaller syringes may increase the internal pressure on the feeding tube. Syringes used for enteral feeding must be non-IV compatible.

To prevent tube damage To minimise discomfort, bloating

and risk of regurgitation. To maintain tube patency and

prevent feed blockage.


PART 3

GUIDELINES FOR THE CARE OF A PATIENT FEEDING VIA A PERCUTANEOUS

ENDOSCOPIC GASTROSTOMY (PEG)


CONTENTS

PAGE

Section 1:

Introduction 20

Section 2:

Consent 20

Section 3:

Indications for PEG 20

Section 4:

Contraindications for PEG 21

Section 5: Section 6:

Referral for PEG Preparation for PEG insertion

22

22

Section 7:

The procedure 22

Section 8:

Types of tube 22

Section 9:

Complications following PEG insertion

23

References/ Bibliography 24 Appendices

Appendix 1 Nursing Care of a Patient with a Percutaneous Endoscopic Gastrostomy

26


1. Introduction 1.1 Feeding tubes placed percutaneously into the stomach with endoscopic

guidance (PEG), allow an alternative route for enteral feeding in those patients who are unable to swallow and where nasogastric feeding is either not possible, or likely to be required for a long period of time. (See Appendix 1 for Procedure for the Nursing Care of a Percutaneous Endoscopic Gastrostomy)

1.2 PEG is never an emergency procedure and cannot be undertaken until the patient has been assessed by a member of the Nutrition Nurse Team or the consultant performing the procedure. 1.1 Appropriate patient selection is essential. Although PEG is considered

a simple and safe procedure, procedure related mortality is approximately 0.7%, overall 30 day mortality in unselected patients around 10.7% (Leeds et al 2009) and the major complication rate is approximately 7.4% (Grant et al 2008). Studies have shown that 20% of patients die within 30 days of PEG insertion, usually due to the underlying disease process or condition (Longcroft-Wheaton et al 2009), suggesting that referral should not be made until the outcome from underlying conditions are more predictable.

2 Consent

2.1 There are many ethical issues, which need to be considered before

embarking on artificial nutrition via PEG. The patient/family/carers must be extensively counselled by a healthcare professional familiar with the procedure, and with the patient, before PEG is requested and the patient must be made aware of the risks and complications when consenting. Involvement of the multi-disciplinary team is essential. PEG will require a change in lifestyle and social circumstances.

2.2 A patient information booklet for PEG feeding is available from the print

room. Code UHB/PI/0281/V3 2.3 Consent for the procedure must be sought in accordance with the

Trust Policy for consent to examination or treatment (current version) and the Mental Capacity Act (2005).

2.4 For patients who lack the capacity to consent themselves, the

referring consultant MUST do so on their behalf by completing and signing Form C (Queen Elizabeth Hospital Birmingham NHS Foundation Trust form for ‘adults who lack the capacity to consent to investigation or treatment’). The signed consent form must accompany the patient to endoscopy and will then be countersigned by the doctor undertaking the procedure. The procedure will not proceed in the absence of informed/appropriate consent.

3 Indications for Percutaneous Endoscopic Gastrostomy PEG


3.1 The following are indications for PEG feeding

A. Permanent impairment of swallowing, i.e.: Dysphagic CVA. The patient must be more than two weeks post

CVA and have had an assessment by a Speech and Language Therapist.

Motor Neurone Disease (MND), Multiple Sclerosis (MS) and other severe neurological impairment, with preserved respiratory function.

B. Planned PEG placement for those undergoing surgery/ radiotherapy

to head and neck. C. Patients needing long term intermittent nasogastric feeding.

NB The following must be taken in to consideration when assessing for a PEG:

Food avoidance is not an indication for PEG. Gastro-oesophageal reflux and aspiration will not be improved with

PEG. PEG feeding will not alter the prognosis from the underlying condition. Studies have shown that aspiration in patients with neurological

dysphagia is not always improved with PEG (Rahnemai-Azar et al 2014)

4 Contraindications for PEG 4.1 Absolute contraindications:

Absence of informed consent or appropriate best interest decision in a patient who lacks capacity to consent.

Inadequate respiratory reserve to undergo sedation or endoscopy, i.e. oxygen saturation, less than 90% on air after exertion

Impaired clotting – Ensure INR less than 1.3, Platelets greater than 100

Gastric malignancy, gastric outlet obstruction, small bowel obstruction.

Peritoneal dialysis Any other circumstances where the risks of the procedure outweigh

the benefits of PEG (Murphy & Lipman 2003)

4.2 Relative Contraindications:

Previous major upper abdominal surgery Abdominal wall sepsis Ascites Gastro-oesophageal reflux and aspiration Morbid obesity Ventriculo-peritoneal shunt


5 Referral for PEG 5.1 All patients must be referred to the Nutrition Nurses for pre PEG

assessment before a booking is made with Endoscopy. Endoscopy departments will not place a patient on a list until they have been seen by the Nutrition Nurses.

The Nutrition Nurses can be contacted on Ext. 14561. 6. Preparation for PEG insertion 6.1 Once accepted for PEG the following are required:

INR and platelets result (checked within 7 days prior to insertion) Consent (as above) Peripheral venous cannula (PVC) to be sited and documented in

the PVC care plan NBM/tube for 6 hours prior to the procedure. However, clear fluids

may be taken up to 2 hours before the procedure. The patient must be able to open their mouth wide enough to

accommodate a mouth guard and the passing of the endoscope.

7. The Procedure 7.1 The procedure is undertaken in the Endoscopy Department. Sedation

(Midazolam) as per Trust Procedure for Conscious Sedation (current version) and a prophylactic dose of antibiotics are usually given.

Occasionally the Nutrition Nurses may make special arrangements with

the surgical team for a PEG to be inserted in theatre if the procedure is likely to be particularly difficult for a specific patient.

A number of patients may have the procedure carried out as a day

case or outpatient if assessed as suitable. In these patients monitoring must take place for 4 hours post procedure prior to discharge.

Patients must receive prophylactic anti biotics in the endoscopy

department prior to PEG insertion, determined by the doctor supervising the procedure, as per British Society of Gastroenterology Guidelines (Allison 2009).

8. Types of Tube 8.1 The majority of patients will have a Fresenius Freka 15FG tube placed. 8.2 Other tubes may be used if clinically appropriate. 8.3 Information on the type of tube placed must accompany the patient

back to the ward.


8.4 Care booklets for all types of tube are available from the Nutrition Nurse Team.

9. Complications following PEG insertion 9.1 From October 2003 to January 2010, the National Patient Safety

Agency (NPSA) received 11 reports of deaths and 11 reports of severe harm describing delay in recognising and acting on signs of complications in the first 72 hours after gastrostomy insertion. The NHS Litigation Authority received 23 claims related to gastrostomies, including seven deaths. Reports suggest that pain on feeding or external leakage of gastric contents were not always recognised as a ‘red flag’ symptom of peritoneal leakage of feed.

9.2 Up to 72 hours post insertion

Respiratory distress / pneumonia Peritonitis Bleeding

Thus if any of the following symptoms occur within this time period the PEG must not be used and urgent medical attention sought to rule out haemorrhage and peritonitis:

Increased pain when flushing or using the PEG Severe/disabling abdominal pain Severe bleeding from the PEG site.

The NPSA alert detailing these red flag symptoms must be routinely included in the endoscopy report. It is essential that this information is passed on to the patient, G.P. and community care teams for all patients being discharged within 72 hours of PEG insertion. 9.3 Late complications:

Exit site infection Tube blockage Tube fracture Tube leakage Over granulation of internal flange (buried bumper) Peritonitis Gastro-colic fistula Granulomas 'Buried bumper' - where the internal retention fixator becomes

buried in the gastric mucosa. This is a serious complication which may require surgery to correct. Therefore, nursing care must be followed as per Appendix 1.


REFERENCES/ BIBLIOGRAPHY Allison MC, Sandoe JAT,Tighe R. Simpson, Hall RJ & Elliott TST(2009)prepared on behalf of the Endoscopy Committee of the British Society of Gastroenterology. Antibiotic prophylaxis in gastrointestinal endoscopy Gut 2009;58:869–880. doi:10.1136/gut.2007.136580 Arrowsmith, H. (1996) Nursing Management of Patients Receiving Gastrostomy Feeding, British Journal of Nursing 5(5), 268-73 Dubgunta S., Still C.D., Kumar A., Maskhdoom Z., Inverso N.A., Komar N.J., Mulhisen L., Rodgers J.Z., Whitmore S. & Whilden B. (2002) Early Initiation of Enteral Feeding after Percutaneous Endoscopic Gastrostomy, Nutrition in Clinical Practice. 17(2): 123-125 Duncan, M., Bray, S., Kapadia, S., Bowling, T., Cole, S., Gabe, S., Walters, E., Silk, D. (1996) Prospective Randomised comparison of two different Percutaneous Endoscopically placed tubes, Clinical Nutrition 15, 317-320 Grant D., Bradley P., Pothier D. Bailey D., Caldera S. , Baldwin D. & Birchall M. (2009) Complications following gastrostomy tube insertion in patients with head and neck cancer: a prospective multi-institution study, systematic review and meta-analysis. Clinical Otolaryngology 8 APR 2009 Haslam, N., Hughes, S., Harrison, R. (1996) Peritoneal leakage of gastric contents. A rare complication of Percutaneous Endoscopic Gastrostomy, Journal of Parenteral and Enteral Nutrition 20 (6), 433-434 Healey F., Sanders D., Lamont T., Scarpello J. & Agbabiaka, T. (2010) Early detection of complications after gastrostomy: summary of a safety report from the National Patient Safety Agency BMJ 2010; 340:c2160 Hull, M.A., Rawlings, J., Murray, F.E., (1993) Audit of outcomes of long-term Enteral Nutrition by Percutaneous Endoscopic Gastrostomy, Lancet 341, 869-872 Leeds. J., McAlidon, M. Grant H, Robson H. Morley S. Lee F. & Sanders D. (2009) Outcomes following gastrostomy: radiologically-inserted v. percutaneous endoscopic gastrostomy. Proceedings of the Nutrition Society 68 (OCE1) Longcroft-Wheaton G., Marden P., Coleypriest B., Gavin D. , Taylor G. & Farrant M. (2009) Understanding Why Patients Die After Gastrostomy Tube Insertion: A Retrospective Analysis of Mortality JPEN J Parenter Enteral Nutr JULY-AUGUST 2009 vol. 33 no. 4 375-379 Mental Capacity Act 2005, http://www.opsi.gov.uk/acts/acts2005/20050009.htm

http://www.opsi.gov.uk/acts/acts2005/20050009.htm


Murphy L. & Lipman T. (2003) Percutaneous Endoscopic Gastrostomy Does Not Prolong Survival in Patients With Dementia Arch Intern Med. 2003;163:1351-1353.

National Patient Safety Agency Early detection of complications after gastrostomy | Gastrostomy RRR | 2010-03-29 | v1 Panos, M., Reilly, H., Moran, A. (1994) Percutaneous Endoscopic Gastrostomy in a General Hospital: Prospective evaluation of indications, outcomes and a randomised comparison of two tube types, Gut. 35: 1551-1556 Rahnemai-Azar A.A, Rahnemaiazar A.A., Naghshizadian R. , Kurtz A, & Farkas D.T. (2014) Percutaneous endoscopic gastrostomy: Indications, technique, complications and management World J Gastroenterology 2014 June 28; 20(24): 7739-7751 ISSN 1007-9327 (print) ISSN 2219-2840 (online) University Hospitals Birmingham NHS Foundation Trust (current version) Policy for consent to examination or treatment, University Hospitals Birmingham NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust (current version) Procedure for Conscious Sedation, University Hospitals Birmingham NHS Foundation Trust


Appendix 1

NURSING CARE OF A PATIENT WITH A

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY

NB Different types of PEG require slightly different care. This is detailed in the appropriate booklets available from the Nutrition Nurse Team The following is common to all tube types:

ACTION

RATIONALE

Up to 72 hours Post Insertion 1. Immediately post insertion record

blood pressure, pulse and respirations every 30 mins for 2 hours then 1 hourly for 2 hours. Inspect the site for bleeding and leakage each time observations are carried out Flush the tube using a 50-60ml purple enteral syringe with 30ml freshly drawn tap water 4 hours after insertion of the tube. Reduce observations to 4 hourly for the next 24 hours for patients who remain as in patients. For day case or out patients the PEG must be flushed with freshly drawn tap water prior to discharge and the patient monitored for any discomfort, See point 7 and 8.

To detect early signs of respiratory distress, bleeding or pain or other symptoms which may suggest development of a major post procedure complication (Healy et al 2010)

2. Observe for abdominal distension, acute abdominal pain and pyrexia.

This may indicate developing peritonitis from a stomach or bowel perforation at the time of procedure

3. Assess and record pain scores.

Administer analgesia as prescribed.

Patients may experience mild discomfort or pain. Sufficient analgesia must be given to allow deep breathing and coughing. This helps to prevent basal consolidation and chest infection.


ACTION

RATIONALE 4. Commence feed as prescribed

by dietitian, 4 hours post insertion of PEG, unless directed otherwise by Nutritional Support Team or Endoscopy Department.

4 hours ‘wait’ will allow patient to recover from procedure and any abdominal distension to subside. (Dubagunta et al 2002)

5.

If a dressing is in situ, change as necessary. A gauze and tape dressing is preferable. However, a dressing should not be necessary after the first 24 hours.

Patient comfort Dressings only used if the exit site is

bleeding.

6. If the PEG tube is not to be used for feeding immediately; flush 6 hourly with 30 mls of freshly drawn tap water (use sterile water if patient is immuno- suppressed/ immuno-compromised)

To maintain tube patency

7. If any of the following symptoms occur DO NOT use the PEG and seek urgent medical attention:

Increased pain when flushing or using the PEG

Severe/disabling abdominal pain

Severe bleeding from the PEG site.

Early detection of post procedure complications

8. Patients who are being discharged home within 72 Hours of PEG insertion must be given the appropriate information leaflet advising them who to contact in the case of concerns: ‘Information for Patients Being Discharged within 72 Hours of PEG or RIG Insertion’ available from the Nutrition Nurses.

Patients and their carers are warned

that the signs listed are danger signs that need urgent attention and are given an appropriate local contact number for urgent aftercare advice that is available overnight and at weekends (NPSA 2010)


ACTION

RATIONALE

Nursing Care Days 1 – 7 1. Clean the area around the

PEG daily, and as required, using water and observe site beneath the fixation device for redness, swelling or evidence of tissue damage. Record skin inspection on Skin Inspection and Assessment Chart (SIAT)

DO NOT LOOSEN THE

EXTERNAL FIXATION DEVICE (unless advised to do so by a member of the Nutrition Support Team or medical staff)

Patient comfort and to reduce the risk of infection. To detect any signs of infection

Allows the gastric wall to adhere

correctly preventing leakage of gastric contents into the peritoneal space

2. Dressings are not necessary for PEG tubes (Arrowsmith 1996). One may be used only if:

there is copious exudate to stop the patient pulling

the tube patient preference.

Patient comfort and preference

3. A gauze type dressing must be used in preference to a film, and this should be changed daily

Film dressings may cause moisture accumulation between the skin and the dressing, increasing the risk of infection

4. Flush tube with 50ml water, using a 50ml purple enteral syringe:

before and after each feed before and after drugs daily if not being used

To maintain patency of tube

5. Patients may shower from day one following PEG. The site must be dried with clean gauze or a clean towel after showering.

Patient comfort.


ACTION

RATIONALE

Nursing Care Day 7 and onwards 1. Continue with flushes and

dressings as previously (days 1-7) Observe site daily for redness, swelling or evidence of tissue damage. Record skin inspection on Skin Inspection and Assessment Chart (SIAT)

As before (i.e. days 1-7)

2. Loosen the external fixation device, noting the number marker at the skin (this will vary according to type of tube

Clean skin and fixation device

Rotate tube through 360° and

move in and out of the stoma approximately 1-2 cm. It is essential that the tube is pushed in to the stomach.

Replace external fixator

snugly against the abdomen, noting number marker and ensuring gentle tension

Stoma tract will have begun to form by day 7 which allows the flange to be loosened safely

Patient comfort and to reduce risk of infection

Rotating/advancing the tube will

promote formation of a straight tract and prevent adherence of internal fixator to the gastric mucosa resulting in 'buried bumper'

External fixator needs to be replaced

in the correct position and at correct tension to prevent leakage

3. If a clip is on the tube its position must be changed daily

Clamping the tube in the same place each time increases risk of tube fracture.

4. The patient may have a bath

after day 7 as long as there are no signs of infection.

The tract around the tube has had sufficient time to heal before it is exposed to bath water


PART 4

GUIDELINES FOR THE CARE OF PATIENTS FEEDING VIA A RADIOLOGICALLY INSERTED

GASTROSTOMY (RIG)

Guidelines for the Care of Patients Requiring Enteral Feeding within University Hospitals Birmingham NHS Foundation Trust. Document control number: CG198 Version 5.4 of 81

CONTENTS

PAGE

Section 1:

Introduction 32

Section 2:

Consent 32

Section 3:

Indications 32

Section 4:

Contraindications 33

Section 5:

Preparation 33

Section 6:

Procedure 34

Section 7: Complications

34

Section 8:

Types of Tubes 35


36

Appendices

Appendix 1 Nursing Care of a Patient Feeding with a Radiologically Inserted Gastrostomy (RIG)

37


1. Introduction

1.1 Feeding tubes placed percutaneously into the stomach with radiological guidance (RIG), allow an alternative route for enteral feeding in those patients who are unable to swallow and where nasogastric feeding is either not possible, or likely to be required for a long period of time. RIG may be the preferred method of feeding compared to PEG in patients who are unable to tolerate an endoscope due to their disease e.g. head/neck cancers or severe respiratory problems (Lawrence et al 2003).

1.2 See Appendix 1 for procedure for the nursing care of a radiologically inserted gastrostomy (RIG).

1.3 RIG is never an emergency procedure, and must not be undertaken

until a member of the Nutrition Support Team or consultant radiologist performing the procedure has assessed the patient. Morbidity and mortality are similar to PEG (Galaski 2009, Leeds et al 2009).

2. Consent

2.1 There are many ethical issues, which should be considered before

embarking on RIG insertion. The patient/family/carers must be extensively counselled before RIG is requested and must be aware of the risks and complications when consenting. RIG will require a change in lifestyle and social circumstances.

2.2 Consent for the procedure must be sought in accordance with the Trust

Policy for consent to examination or treatment (current version) and the Mental Capacity Act (2005).

2.3 For patients who are unable to consent themselves, the referring

consultant MUST do so on their behalf by completing and signing Form C (University Hospitals Birmingham NHS Foundation Trust form

for ‘adults who lack the capacity to consent to investigation or treatment’. The signed consent form must accompany the patient to the radiology department and will then be countersigned by the doctor undertaking the procedure. The procedure will not go ahead in the absence of informed/appropriate consent.

3. Indications for Radiologically Inserted Gastrostomy (RIG) 3.1 The following are indications for a RIG in patients who are not able to

undergo PEG:

A. Permanent impairment of swallowing,


Dysphagic CVA. Must be more than two weeks post CVA and had speech and language therapy (SALT) assessment.

Motor neurone disease (MND), multiple sclerosis(MS) and other

severe neurological impairments

B. Planned placement for those undergoing surgery/radiotherapy to the head and neck.

C. Patients needing long term intermittent nasogastric feeding.

D. Decompression for mechanical obstruction, Gastroparesis.

NB The following must be taken in consideration when assessing for a RIG:

Food avoidance is not an indication for RIG. Gastro-oesophageal reflux and aspiration will not be improved with RIG. RIG feeding will not alter the prognosis from the underlying condition.

4. Contraindications 4.1 Absolute Contraindications:

Absence of informed consent or appropriate best interest decision in a patient who lacks capacity to consent.

Impaired clotting – Ensure INR less than 1.3 , platelets greater than 100

Gastric malignancy Gastric outflow or small bowel obstruction Inability to insert a naso-gastric tube (The NG tube is used for

gastric insufflation during the procedure)

4.2 Relative Contraindications:

Previous major upper abdominal surgery Abdominal wall sepsis Morbid obesity Ventriculoperitoneal shunt Liver enlargement (this may obscure access to the stomach)

5. Preparation 5.1 Patients must be referred to the Nutrition Nurses for assessment and counselling for RIG.

Once accepted for RIG, the following are required prior to the procedure:


Consent as above INR and platelets checked in last 7 days Nasogastric tube placement for insufflation of the stomach during

RIG (either fine bore feeding tube or Ryles type is acceptable) Peripheral intravenous cannula to be sited Nil By Mouth –6 hours prior to procedure for food –2 hours prior to procedure for clear fluids

6. Procedure 6.1 The procedure is undertaken in the Radiology Department. Sedation (Midazolam) as per Trust Procedure for Conscious Sedation (current version), narcotic analgesia and prophylactic antibiotics are usually given.

6.2 Gastropexy, (securing of the stomach to the anterior abdominal wall with a type of suture) is usually performed. This must be documented by the radiologist. 7. Complications 7.1 From October 2003 to January 2010, the National Patient Safety

Agency (NPSA) received 11 reports of deaths and 11 reports of severe harm describing delay in recognising and acting on signs of complications in the first 72 hours after gastrostomy insertion. The NHS Litigation Authority also received 23 claims related to gastrostomies, including seven deaths. Reports suggested that pain on feeding or external leakage of gastric contents were not always recognised as a ‘red flag’ symptom of peritoneal leakage of feed. See Appendix 1 for procedure for the nursing care of a radiologically inserted gastrostomy (RIG)

7.2 Early complications:

Peritonitis (local or generalised) Bleeding Pain

Thus if any of the following symptoms occur within this time period the gastrostomy must not be used and urgent medical attention sought to rule out haemorrhage and peritonitis:

Increased pain when flushing or using the gastrostomy Severe/disabling abdominal pain Severe bleeding from the gastrostomy site.

The Interventional Radiologist who inserted the RIG should be contacted or, in their absence, the case should be discussed with another Interventional Radiologist.


7.3 Late complication: Exit site infection Tube blockage Tube fracture Tube leakage Granuloma at the site

8. Types of Tubes 8.1 This will normally be a balloon retained gastrostomy tube with 2- 3 gastropexy sutures/buttons to secure the stomach to the

anterior abdominal wall.

Balloon retained tubes may fall out or become displaced if the water in the balloon is not checked and replaced weekly. Therefore, nursing care as per Appendix 1 must be carried out.

8.2 Balloon retained gastrostomy tubes require elective changing

every 3-6 months. Replacement tubes are available and the Nutrition Nurses should be contacted for advice and/or patient follow up.


REFERENCES/BIBLIOGRAPHY Galaski A., Peng Wei Wei, Ellis M., Darling P., Common A. & Tucker E. (2009) Gastrostomy tube placement by radiological versus endoscopic methods in an acute care setting: A retrospective review of frequency, indications, complications and outcomes. Can J Gastroenterol. 2009 February; 23(2): 109–114. Haslam, N., Hughes, S., Harrison, R. (1996) Peritoneal leakage of gastric contents. A rare complication of Percutaneous Endoscopic Gastrostomy, Journal of Parenteral and Enteral Nutrition 20 (6), 433-434 Healey F., Sanders D., Lamont T., Scarpello J. & Agbabiaka, T. (2010) Early detection of complications after gastrostomy: summary of a safety report from the National Patient Safety Agency BMJ 2010; 340:c2160 Lawrence. J, Mais. K & Slevin N. (2003) Radiologically Inserted Gastrostomies: Their use in Patients with Cancer of the Upper Aerodigestive Tract. Clinical Oncology. 15:87-91 Leeds. J., McAlidon, M. Grant H, Robson H. Morley S. Lee F. & Sanders D. (2009) Outcomes following gastrostomy: radiologically-inserted v. percutaneous endoscopic gastrostomy. Proceedings of the Nutrition Society 68 (OCE1) Mental Capacity Act 2005, http://www.opsi.gov.uk/acts/acts2005/20050009.htm National Patient Safety Agency (2010) Early detection of complications after gastrostomy | Gastrostomy RRR | 2010-03-29 | v1 Panos, M., Reilly, H., Moran, A. (1994) Percutaneous Endoscopic Gastrostomy in a General Hospital: Prospective evaluation of indications, outcomes and a randomised comparison of two tube types, Gut. 35: 1551-1556 University Hospital Birmingham NHS Foundation Trust (2008) Policy for consent to examination or treatment, University Hospital Birmingham NHS Foundation Trust University Hospital Birmingham NHS Foundation Trust Procedure for Conscious Sedation (current version), University Hospital Birmingham NHS Foundation Trust

http://www.opsi.gov.uk/acts/acts2005/20050009.htm


Appendix 1

NURSING CARE OF A PATIENTS FEEDING VIA A

RADIOLOGICALLY INSERTED GASTROSTOMY (RIG)

ACTION

RATIONALE Immediately Post Insertion

1. Immediately post insertion record blood pressure, pulse and respirations every 30 minutes for 2 hours then 1 hourly for 2 hours. Inspect the site for signs of bleeding or leakage each time observations are carried out. Flush the tube using a 50-60ml purple enteral syringe with 30ml freshly drawn tap water 4 hours after insertion of the tube. Reduce observations to 4 hourly for the next 24 hours for patients who remain as in patients. For daycase patients the RIG tube must be flushed with freshly drawn tap water prior to discharge and the patient monitored for any discomfort

To detect early signs of respiratory distress, bleeding or pain or other symptoms which may suggest development of a major post procedure complication (Healy et al 2010)

2. Observe for abdominal distension, acute abdominal pain and pyrexia If any of the following symptoms occur DO NOT use the RIG and seek urgent medical attention:

Increased pain when flushing or using the PEG

Severe/disabling abdominal pain Severe bleeding from the PEG

site.

This may indicate developing peritonitis from a stomach or bowel perforation at the time of the procedure

3. Assess and record pain score. Administer analgesia as prescribed.

Patients may experience mild discomfort or pain. Sufficient analgesia must be administered to allow deep breathing and coughing. This helps to prevent


basal consolidation and chest infection

4. Commence feed as prescribed by dietician 4 hours post insertion unless directed otherwise by Nutritional Support Team or Radiology Department If able to eat/drink the patient can do so at this point

4 hours wait will allow patient to recover from procedure and any abdominal distension to subside

5. If the RIG tube is not to be used for feeding immediately, flush 6 hourly with 30mls of freshly drawn tap water (use sterile water if patient is immuno-suppressed/ immuno-compromised)

To maintain tube patency

ACTION

RATIONALE Monitoring: Up to 72 hours post insertion 1. For in patients:

Continue to observe the site for any signs of bleeding or leakage of gastric contents

Observe patient for signs of severe abdominal pain or increased pain on feeding/flushing.

If these symptoms occur stop feed immediately and seek medical advice.

These may be signs that the patient is developing peritonitis. (NPSA 2010)

2 Continue with observations but reduce to twice daily if the patient is stable

3 Patients being discharged within 72 hours of RIG insertion

These patients must be seen by the Nutrition Nurses prior to discharge and be given written information regarding what action to take should they experience any of the above symptoms.

Major complications such as peritonitis should become evident within 72 hours of the procedure Patients must be informed of what symptoms may indicate there is a serious problem and be given a 24 hour contact for emergencies. (NPSA 2010)


ACTION

RATIONALE Nursing Care Days 1-14 1. Clean the area around the RIG and

gastropexy sutures/buttons daily as required using warm water. Observe site beneath the fixation device and gastropexy sutures daily for redness, swelling or evidence of tissue damage. Record skin inspection on Skin Inspection and Assessment Chart (SIAT) Patients may shower from day one following RIG. The site must be dried with clean gauze or a clean towel after showering.

Patient comfort and to reduce the risk of infection and monitor exit site

2. Dressings are not necessary for Gastrostomy tubes (Arrowsmith 1996) However, one may be used if there is Copious exudate To stop the patient pulling the tube Patient preference

Patient comfort and preference.

3. If required a gauze type dressing should be used in preference to a film, and this should be changed regularly using a clean technique

Film dressings may cause moisture accumulation between the skin and the dressing, increasing the risk of infection

4. The position of the external fixator must be documented daily.

It should be possible to apply gentle traction to the tube and return the fixator to approx 2mm above the abdomen

To ensure correct tube positioning, prevent peristomal leakage and over granulation of the site.

The fixator must not be too tight due to the risk of tissue necrosis

5. Flush tube with 50ml water, using a

50ml purple enteral syringe; Before and after each feed Before and after drugs Daily if not being used

To maintain patency of tube

6. Patients who are being discharged home with a RIG must receive adequate training in tube and feed management prior to discharge. Arrangements for tube changes must be made prior to discharge. Contact the Nutrition Nurses for advice.

To ensure the patient can safely manage their tube.

To ensure appropriate follow up is

arranged.


ACTION

RATIONALE Nursing/ongoing care Day 14 onwards 1. Continue with flushes as previously.

Dressings should not be required after the first couple of weeks. Observe site daily for redness, swelling or evidence of tissue damage. Record skin inspection on Skin Inspection and Assessment Chart (SIAT)

As before

2. Any gastropexy sutures should begin to dissolve and the buttons fall off by week 2-3. If this has not happened by week 6 contact the Nutrition Nurses for advice.

Tract now formed and stomach is adhered to abdominal wall.

3 The patient may have a bath after day 7 as long as there are no signs of infection.

The tract around the tube has had sufficient time to heal before it is exposed to bath water

4. Rotate the tube in complete circle

weekly after day 14

Promote straight tract

5 Check the water volume in the balloon on a weekly basis by: Checking on the valve how much

water it should contain e.g. 5mls Withdrawing the water with a

standard i/v slip syringe and noting how much is retrieved (Discard old water)

Replacing the correct amount of sterile water with a slip syringe into the balloon

Document the above (See Part 6, Care of a Patient Receiving Feed via a Balloon Retained Gastrostomy)

A small amount of water will be lost from the balloon through osmosis.

The amount of water required

may vary with different tubes and tube sizes.

To ensure correct inflation of the

balloon and reduce the risk of leakage and rupture

To ensure accurate documentation

6

TUBE DISPLACEMENT In the event of the balloon

gastrostomy tube coming out a Foley

To maintain the stoma tract. The

tract will begin to close within 1-2


catheter, of a similar French gauge, should be inserted into the stoma tract as quickly as possible. Seek the patients consent prior to carrying out the procedure.

CONTACT THE NUTRITION

NURSES OR A CONSULTANT RADIOLOGIST OUT OF HOURS, IMMEDIATELY FOR A REPLACEMENT FEEDING TUBE.

Do not feed through the Foley catheter If any difficulty was experienced, or there is any uncertainty with regards to the tube position then: Leave the catheter in situ Contact the Nutrition Nurses as soon as possible

hours resulting in the loss of this feeding route (NMPDU, Scotland 2003).

A Medical Devices Alert

(MDA/2004/006) stipulated that devices should only be used for the purpose for which they were intended i.e. a Foley catheter for urine drainage. However, in weighing up the risks to the patient of losing their feeding route against the potential risks of using a Foley catheter outside of license, it is acceptable for a Foley catheter to be used to maintain a stoma tract as a short term measure. It must not be used for feeding and should be changed to a replacement feeding tube as quickly as possible.


PART 5

GUIDELINES FOR THE CARE OF A PATIENT FEEDING VIA A BALLOON RETAINED

GASTROSTOMY TUBE


CONTENTS PAGE

Section 1: Introduction

44

Section 2: Advantages/ Disadvantages of Balloon Retained Gastrostomy Tubes

44

Section 3: Indications/Contraindications for Balloon Retained Gastrostomy Tubes

44

Section 4: Types of Balloon Retained Gastrostomy Tubes

45


46

Appendices

Appendix 1

Nursing care of a Patient Receiving Feed Via a Balloon Retained Gastrostomy Tube

47


1. Introduction 1.1 Balloon retained gastrostomy tubes have an internal balloon for fixation

(as is common in RIG)rather than a plastic flange (as is common in PEG) and are a useful alternatives and/or replacement tubes for patients with a mature stoma tract. They do have a number of advantages and disadvantages and their use must be carefully considered in conjunction with the patient’s wishes.

1.2 See Appendix 1 for procedure for the care of a patient receiving feed via a balloon retained gastrostomy tube. 1.3 In addition, balloon retained gastrostomy tubes are frequently used as

an initial placement device in Radiologically Inserted Gastrostomy (RIG) with gastropexy sutures to secure the stomach post procedure.

1.4 Where a balloon retained tube has been inserted as part of a RIG

procedure see Part 5 Guidelines for the Care of Patients Feeding via a Radiologically Inserted Gastrostomy (RIG).

2. Advantages/ Disadvantages of Balloon Retained Gastrostomy

Tubes 2.1 Advantages:

Easily changed in the community, some patients/carers can be trained to do this, thus reducing hospital attendance

Availability of low profile devices (buttons), more aesthetically acceptable

2.2 Disadvantages:

Require changing every 3-6 months Therefore, more expensive than standard PEG in terms of device

cost and potential nursing input. Involves more care than standard PEG ; balloon water volume must

be checked weekly Risk of balloon rupture resulting in lost tube and closure of stoma

tract 3. Indications/Contraindications for Balloon Retained Gastrostomy

Tubes 3.1 Indications:


Patients who cannot undergo endoscopy procedure for PEG change e.g. head/neck patients

Replacement tube for worn out PEG Replacement tube when an existing tube has become displaced Patients requiring a more discrete device i.e. low profile As an initial placement tube in RIG

3.2 Absolute Contraindications for replacing a Balloon Retained

Gastrostomy Tube:

Stoma tract of less than 30 days old (Taheri et al 2011) 3.3 Relative Contraindications:

Acutely angled stoma tract – more difficult to place. However insertion may be attempted depending on patient wishes.

4. Types of Balloon Retained Gastrostomy Tubes 4.1 A balloon retained gastrostomy tube is easily recognised as such due

to the presence of a valve near the feeding port. This valve is for the balloon inflation/deflation and is absent on any other type of feeding tube.

4.2 The Nutrition Nurses will be able to advise on which type of balloon retained tube the patient has in situ. 4.3 Some commonly used gastrostomy tubes are the Flocare, Corflo and Vygon tubes which are available in a variety of French gauges. 4.4 Commonly used low profile devices include the MIC-Key button (Vygon) and the CuBBY button (Merck). Again, these are available in a variety of French gauges and shaft lengths.


REFERENCES/ BIBLIOGRAPHY Arrowsmith H. (1996) Nursing Management of Patients Receiving Gastrostomy Feeding. British Journal of Nursing 5(5), 268-273 Burnham P. (2000) A Guide to Nasogastric tube insertion. Nursing Times (supp) 86(8) 6-7. CREST (2004) Guidelines For the Management of Enteral Tube Feeding in Adults. Clinical Resource Efficiency Support Team, April 2004 Lohsiriwat V. (2013) Percutaneous endoscopic gastrostomy tube replacement: A simple procedure? World J Gastrointest Endosc 2013 January 16; 5(1): 14-18 ISSN 1948-5190 (online) MDA/2004/006 Medical Devices Alert Nursing & Midwifery Practice Development Unit (2003) Nasogastric and Gastrostomy Tube Feeding for Children Being Cared for in the Community. Best Practice Statement. NHS Quality Improvement Scotland.

Ojo O. (2011) Balloon gastrostomy tubes for long-term feeding in the community. British Journal of Nursing (BJN), vol./is. 20/1(34-38),

Taheri MR, Singh H & Duerksen DR (2011) Peritonitis After Gastrostomy Tube Replacement: Case Series and Review of Literature JPEN Journal of Parenteral and Enteral Nutrition January 2011 vol. 35 no. 1 56-60

http://www.library.nhs.uk/details.aspx?t=balloon+gastrostomy+tube&stfo=False&sc=bnj,evi,gui,spl&p=1&sf=srt.default&sr=bnj.ebs&sfld=fld.any&tab=&did=2010909264&pc=33&id=0

http://www.library.nhs.uk/details.aspx?t=balloon+gastrostomy+tube&stfo=False&sc=bnj,evi,gui,spl&p=1&sf=srt.default&sr=bnj.ebs&sfld=fld.any&tab=&did=2010909264&pc=33&id=0


Appendix 1

NURSING CARE OF A PATIENT RECEIVING FEED VIA A BALLOON RETAINED GASTROSTOMY TUBE

ACTION

RATIONALE

1.

Clean the area around the tube daily, and as required, with warm water and dry thoroughly.

Observe site beneath the fixation device daily for redness, swelling or evidence of tissue damage. Record skin inspection on Skin Inspection and Assessment Chart (SIAT)

For patient comfort and to reduce the risk of infection.

To detect any signs of infection.

2.

Dressings are not necessary for Gastrostomy tubes (Arrowsmith 1996) However, one may be used if there is Copious exudate Prevent patient pulling the tube Patient preference

Patient comfort and preference.

3.

A gauze type dressing should be used in preference to a film, and this should be changed regularly.

Film dressing may cause moisture to accumulate around the site increasing the risk of infection.

4.

Flush the tube with 50ml of freshly drawn tap water, using a 50ml purple enteral syringe : Before and after every feed Before and after drug

administration Daily if not being used

To maintain tube patency.

5.

Rotate the tube through 360 degrees daily

To encourage a healthy stoma tract

6.

The position of the external fixator must be documented daily.

It should be possible to

apply gentle traction to the

To ensure correct tube positioning, prevent peristomal leakage and over granulation of the site.

The fixator must not be too tight due

to the risk of tissue necrosis


tube and return the fixator to approx ½ -1 cm above the abdomen

7.

Check the water volume in the balloon on a weekly basis by: Checking on the valve how

much water it should contain e.g. 5mls

Withdrawing the water with a standard i/v slip syringe and noting how much is retrieved (Discard the old water)

Replacing the correct amount of sterile water with an i/v slip syringe into the balloon

Document the above

A small amount of water will be lost from the balloon through osmosis.

The amount of water required may

vary with different tubes and tube sizes.

To ensure correct inflation of the

balloon and reduce the risk of leakage and rupture

To ensure accurate documentation

8.

TUBE DISPLACEMENT In the event of the balloon

gastrostomy tube coming out a Foley catheter, of a similar French gauge, should be inserted into the stoma tract as quickly as possible. Seek the patients consent prior to carrying out the procedure.

CONTACT THE NUTRITION

NURSES DURING OFFICE HOURS FOR A REPLACEMENT FEEDING TUBE. OUT OF HOURS CONTACT A CONSULTANT INTERVENTIONAL RADIOLOGIST FOR ADVICE.

Do not feed through the Foley catheter If any difficulty was experienced, or there is any uncertainty with regards to the tube position then: Leave the catheter in situ Contact the Nutrition

Nurses as soon as possible

To maintain the stoma tract. The

tract will begin to close within 1-2 hours resulting in the loss of this feeding route (NMPDU, Scotland 2003).

A Medical Devices Alert

(MDA/2004/006) stipulated that devices should only be used for the purpose for which they were intended i.e. a Foley catheter for urine drainage. However, in weighing up the risks to the patient of losing their feeding route against the potential risks of using a Foley catheter outside of license, it is acceptable for a Foley catheter to be used to maintain a stoma tract as a short term measure. It must not be used for feeding and must be changed to a replacement feeding tube as quickly as possible.


PART 6

GUIDELINES FOR CARE OF PATIENTS FEEDING VIA A SURGICALY PLACED JEJUNOSTOMY


CONTENTS PAGE Section 1: Indications 51 Section 2: Contra-indications 51 Section 3: Insertion 51 Section 4: Types of tube 51 Section 5: Complications 52 References/Bibliography 53 Appendices Appendix 1 Nursing Care of patients feeding via a surgically placed

jejunostomy 54


1. Indications 1.1 Some patients experience medical problems or undergo surgery after which it may be impossible to feed them into their stomach. This may be a short term problem, immediately after surgery or in some instances may be the only way in which the patient can be fed in the long term at home. Those needing short term jejunal feeding can sometimes be managed with a naso-jejunal feeding tube, however occasionally this may not be suitable and jejunal feeding may be considered via a surgically placed jejunostomy (Stroud et al 2003). (See Appendix 1 nursing care of patients feeding via a surgical jejunostomy) 1.2 This may include patients with the following problems:

Diseases of the oesophagus Oesophagectomy Gastroparesis Gastrectomy Gastro-oesophageal reflux Delayed gastric emptying Laryngectomy with jejunal graft Gastrointestinal dysmotility

2. Contra-indications Patients with a lower gastrointestinal obstruction are not suitable for

enteral feeding and, therefore, jejunostomy is contra-indicated. Lack of informed consent. 3. Insertion 3.1 Insertion of a jejunostomy feeding tube is usually carried out in theatre. 3.2 It may be performed as a standalone procedure, or as part of a more

complex operation, such as Oesophagectomy.

4. Type of Tubes 4.1 There are a variety of tubes available; however, commonly used tubes

include a Freka 9fg jejunostomy feeding tube, a Freka 15fg gastric tube (i.e. PEG tube), a balloon retained gastrostomy tube.

4.2 The Nutrition Nurses must be contacted if there is any concern

regarding the make or position of a feeding tube.


5. Complications 5.1 Complications associated with feeding through and ongoing care of a

jejunostomy includes:

abdominal distension diarrhoea. This may be due to drug therapy administered via

the tube, excessive water delivered via the tube, resulting in an osmotic diarrhoea or malposition of the tube in the jejunum

tube blockage site infection leakage of bowel contents from the site tube displacement if the retaining sutures or dressing

become loose on a Freka 9fg jejunostomy tube bowel ischaemia

(De Brabandere et al 2010)


REFERENCES/BIBLIOGRAPHY Braga M., Gianotti L., Gentilini A., Liotta S., Di Carlo V., (2001) Feeding the Gut After Digestive Surgery: Results of a Nine Year Experience. Clinical Nutrition. 21(1) 59-65

De Brabandere K, De Waele B& Delvaux G. (2010) Colonic Ischemia and Perforation Associated With Enteral Feeding Through an Ileal Tube Nutrition in Clinical Practice, June 2010; vol. 25, 3: pp. 301-303.

ICNA (2003) Enteral Feeding Infection Control Guidelines. Infection Control Nurses Association Stroud M., Duncan H. & Nightingale J. (2003) Guideline for Enteral Feeding in Adult Hospital Patients. Gut 2003;52 (Suppl VII, vii-vii) 2 White R. & Bradnam V. (2015) Handbook of Drug Administration via Enteral Feeding Tubes 3rd edition. Pharmaceutical Press


Appendix 1

NURSING CARE OF A PATIENT FEEDING VIA A

SURGICALLY PLACED JEJUNOSTOMY ACTION RATIONALE

1.

Tube Flushing The jejunostomy tube must be flushed with 50 ml of freshly drawn tap water via a 50-60ml enteral syringe.

Before and after feed Daily if the tube is not in

use Drug Therapy

Before and after drugs Flush 10ml water

between individual drugs For severely immune-compromised patients either freshly opened, sterile water or cooled boiled water may be used for flushing.

Regular flushing helps prevent tube blockage.

Drug therapy via these tubes is often a problem in causing blockages

Severely Immuno-compromised patients may be more susceptible to infection.

2.

Cleaning the site Clean the jejunostomy site daily with warm water and dry thoroughly. Freka 9fg Jejunostomy tube Apply a film type dressing to the site, completely covering the triangular flange. Each day inspect the retaining sutures at the triangular flange for:

Any signs of skin soreness

To ensure they are still securing the tube.

To keep the site clean and prevent infection.

A film dressing is effective at securing the triangular flange and allows easy inspection of the site.

Sutures may need replacing at

intervals.


Record skin inspection on Skin Inspection and Assessment Chart (SIAT)

If the sutures become loose and the decision is made not to replace them, the film dressing can be used to secure the tube. However, care must be taken when changing the dressing to prevent tube displacement. Other types of tube No dressing is necessary unless there is leakage at the site Observe site beneath the fixation device daily for redness, swelling or evidence of tissue damage. Record skin inspection on Skin Inspection and Assessment Chart (SIAT)

Some patients may prefer not to have repeated re-suturing of the tube and manage securing the tube with a dressing.

Tubes designed for gastric

use (i.e. PEG or balloon retained gastrostomy) have an internal bumper or balloon that secures the tube in position. Therefore sutures are not required at the site.

3.

Do not rotate the feeding tube

Jejunal tubes do not need to be rotated due to likely dislodgement of the retaining sutures or tube.

4.

Observe patients for abdominal distension

This may be a sign that the patient is not absorbing their feed, although other causes of abdominal distension should also be considered.

5.

3 way taps must not be used between the tube and giving set

Each additional connector increases risk of contamination (ICNA 2003).

The use of a 3 way tap makes

the system compatible with IV giving sets and increases the risk of inadvertent infusion of enteral products via an IV catheter.

6.

Discuss with a Pharmacist before administering medicines via a jejunostomy feeding tube.

Some medicines may not be suitable for administration via the jejunal route, for example those that need to be absorbed in the stomach


(White and Bradnam 2015) Other medicines may be

particularly likely to cause tube blockages, such as Lansoprazole or Ciprofloxacin suspension.

7.

Starting/advancing feed rate: Follow dietitian’s instructions. In the absence of a dietitian refer to Part 1 of these guidelines

Starting at a low rate and advancing slowly reduces the incidence of GI side effects (Braga et al 2001)

8.

if the patient has a nasogastric tube for stomach decompression this must be aspirated 4 hourly to reduce the risk of vomiting Aspiration of large volumes of naso-gastric aspirate is not a reason to reduce or discontinue jejunal feeding, unless the aspirate obviously contains feed. If the aspirate contains feed, stop the feed and contact medical staff for review.

Vomiting is unpleasant for the patient.

Jejunostomy tubes deliver the feed below the stomach. The indication for insertion is often poor gastric emptying and high gastric aspirates/vomiting.

If there is feed present in

gastric aspirate it may indicate distal obstruction (possibly secondary to constipation).


PART 7

GUIDELINES FOR THE ADMINISTRATION OF DRUGS VIA ENTERAL FEEDING TUBES IN ACCORDANCE

WITH TRUST MEDICINES POLICY AND PROCEDURE

Note: Please refer to the Trust Procedure For The Insertion And Management Of Fine Bore Nasogastric Feeding Tubes in Adult Patients if using a fine bore NG feeding tube. Or


CONTENTS

PAGE

Section 1

Introduction 59

Section 2 Liability

59

Section 3 Drug/feed interactions

59

Section 4 Drug/drug interactions

60

Section 5 Drug Preparations

60

Section 6 Site of Absorption

61

Section 7 Section 8

Choice of Syringe Reference Resource

61

61

Reference Resources

Appendices

62

Appendix 1 Copy of BAPEN Poster – Administration of Drugs via Enteral Feeding Tubes

63


1. Introduction

1.1 The administration of drugs via enteral feeding tubes is common practice in patients who are not able to take medication orally. However, there are problems associated with this practice. Those prescribing and/or administering medication in this manner must be aware of possible drug interactions and issues of liability.

NB

A pharmacist should always be consulted for advice on the appropriateness of delivering medication to individual patients via an enteral feeding tube.

2. Liability

2.1 The product licence of a medication indicates the conditions under which a drug can be safely administered. Anyone administering a drug outside of those conditions assumes a degree of liability for any adverse effects (Greenwall 2003). For example, crushing a tablet that was designed to be swallowed whole is outside of that drug’s product licence. 2.2 However, it is generally accepted that, in certain circumstances, this practice is unavoidable in enabling professionals to act in the patient’s best interest. 2.3 The patient’s prescription chart/ PICS prescription must indicate via

which route they should be receiving their medication. If it is intended for a drug to be given via PEG/NGT/PEJ etc. it must be documented in the appropriate section. All drugs must be prescribed and administered in accordance with the Trust Medicines Policy and Procedures (current version).

3. Drug/Feed Interactions

3.1 The timing of drug administration can interfere with the absorption and effect of the drug and may be a factor in treatment failure. For example, serum levels of Phenytoin are significantly reduced in patients who are given enteral feeds within 1-2 hours of the drug administration (Faraji & Yu 1998). 3.2 Drugs must never be added to enteral feed containers due to the risk of unknown interactions and the unpredictability of administration of enteral feeds.


4. Drug/Drug Interactions

4.1 Each drug must be given individually and not crushed or mixed together. This is extremely important in preventing unknown drug/drug interactions. There must be a flush of at least 10mls water between each drug administered to ensure they do not mix within the feeding tube. 5. Drug Preparations

5.1 A soluble or liquid formulation is preferred when drugs are to be given

via an enteral feeding tube. It is worth noting that some liquid preparations may be hypertonic and/or contain large amounts of sorbitol resulting in osmotic diarrhoea. In addition some liquid medicines are suspensions which contain small granules/particles which can block tubes, e.g. Ciprofloxacin, Clindamycin.

5.2 When changing from tablet form to a liquid preparation, doses may differ, therefore, a pharmacist’s advice is necessary in amending the prescription accordingly. Drugs with a narrow therapeutic range can be

particularly difficult due to different formulations of the same drug having different bioavailability. An example of this is Digoxin.

5.3 Crushing tablets or opening capsules is a last resort and should be discussed with a pharmacist first. Some tablets that are not marketed as dispersible will, in fact, dissolve in water if given enough time e.g. Co-dydramol. 5.4 Tablets that should not be crushed include:

Enteric coated (EC): the coating is designed to resist gastric acid,

to protect the drug and/or reduce gastric side effects Modified/ Slow Release (MR, SR, LA, XL): these are tablets or

capsules that are specifically designed to release the drug over a long period of time. Crushing these will cause all the drug to be released at once and may cause toxic side effects. However some modified release preparations are granulated inside capsules and can be given as long as they are not crushed – seek pharmacist advice.

Cytotoxic and hormones: these must not be crushed due to the

risks to staff from exposure to the powdered drug

Sub-lingual, buccal, ‘melt’, chewable:


Proton pump inhibitors. these drugs have coatings which are designed to dissolve in the jejunum rather than the stomach. Oridispersible preparations may be used – seek pharmacist advice

5.5 Dilution of liquid preparations

Small volumes and viscous liquids should be diluted before administration unless otherwise advised (advice to be obtained from pharmacist). Freshly drawn cold tap water e.g. 20mls (or sterile water for Bone Marrow Transplant {BMT} patients) should be used for dilution.

6. Site of Absorption

6.1 Giving drugs via jejunostomy/nasojejunal tubes present particular problems in terms of drug absorption. Some drugs are absorbed or activated in the stomach. With the feeding tube placed in the small bowel this mechanism is bypassed. NB This must always be discussed with a pharmacist as alternative routes/medications may need to be considered E.g. patches, suppositories or IV 7. Choice of Syringe

7.1 Although liquid preparations less than 5mls in dosage need to be

measured in small syringes for accuracy, these syringes must be purple enteral syringes not intravenous (IV). Standard syringes are IV compatible and pose a safety hazard when the drug is to be given via a non IV route.

7.2 Once measured, the drug should be diluted with freshly drawn tap

water (or sterile water for BMT patients) then must be drawn up in a 50ml purple enteral syringe for administration via an enteral feeding tube.

8. Reference resource

8.1 Practical information on the correct administration of drugs via enteral feeding tubes is available via BAPEN (British Association for Parenteral and Enteral Nutrition) as a poster (see Appendix 1) for display in clinical areas. 8.2 The Pharmacy Departments and the Nutrition Nurses have access to

information regarding the best way to administer individual drugs via the Handbook of Drug Administration via Enteral Feeding Tubes.


REFERENCES/BIBLIOGRAPHY British Association for Parenteral and Enteral Nutrition & British Pharmaceutical Nutrition Group (2003) Drug Administration via Enteral Feeding Tubes. Faraji B & Yu P. (1998) Serum Phenytoin Levels of Patients on Gastrostomy Tube Feeding. Journal of Neuroscience Nursing. 30(1) 55-59 Greenwall R.S. (2003) Medication Management of the Elderly. A Guide for Nursing Staff. Rosemont Pharmaceuticals. Magnuson B.L. , Clifford T.M. Hoskins L.A. & Bernard A.C. (2005) Enteral Nutrition and Drug Administration, Interactions, and Complications Nutrition in Clinical Practice, December 2005; vol. 20, 6: pp. 618-624. University Hospitals Birmingham NHS Foundation Trust (current version) Medicines Policy. University Hospitals Birmingham NHS Foundation Trust White R. & Bradnam V. (2010) Handbook of Drug Administration via Enteral Feeding Tubes 2nd edition. Pharmaceutical Press UK


Appendix 1:British Association for Parenteral and Enteral Nutrition

UNLICENSED ROUTES Crushing tablets, opening capsules and administration via feeding tubes generally falls outside a drug’s product licence. In these circumstances the prescriber and practitioner accept liability for any adverse effects resulting from the administration

STEP BY STEP GUIDE Can the patient still take their medication orally?

Do not add medication directly to the feed Seek further advice for fluid restricted or paediatric patients as flushing

volumes may need to be reduced Review all medication. Is it all really necessary

Can an alternative route be used? Do you need to allow a break before administering the medicines?

Do you need to allow a break before restarting the feed?

For further advice contact your local hospital Medicines Information Department

Produced by the British Association for Parenteral and Enteral Nutrition www.bapen.org.uk Registered Charity 1023927

and The British Pharmaceutical Nutrition Group www.bpng.co.uk

PREFERRED FORMULATIONS Liquids or soluble tablets are the

preferred formulations to be administered via a feeding tube

Some injections can be given enterally *Crushing tablets or opening

capsules should be considered a last resort

MEDICINES THAT SHOULD NOT BE CRUSHED Enteric Coated (EC): The coating is

designed to resist gastric acid to protect the drug and/or reduce gastric side effects.

Modified/Slow Release (MR, SR, LA, XL): These are tablets or capsules that are specifically designed to release the drug over a long period of time. Crushing these will cause the entire drug to be released at once and may cause toxic side effects.

+Cytotoxics & Hormones: These should not be crushed due to the risks to staff from exposure to the powdered drug.

TUBE TIP POSITION Check the drug is absorbed

from the site of delivery This can be a problem for

jejunal tubes (some drugs have a reduced absorption).

WHICH TYPE OF WATER Check local policy The type of water

recommended depends on local practice and the exit site of the tube

SYRINGE SIZE AND TYPE 50ml oral, enteral or catheter

tipped syringe should be used It may be necessary to use a

specially designed connector. A smaller syringe may

produce too much pressure and split the tube (check manufacturers guidelines)

Do not use syringes intended for intravenous use due to the risk of accidental parenteral administration

INFECTION CONTROL AND SAFETY Wash hands and wear

gloves. It is important that exposure

to drug powder is kept to a minimum

TUBE BLOCKAGE Inadequate flushing is the

most common cause of tube blockage

Using the wrong formulation of medication can also cause tube blockage

If flushing with warm water does not unblock the tube, seek specialist advice, do not apply excessive force.

DISCHARGE PLANNING Ensure the agreed feed and

drug regimen are practical in a community setting

Ensure all information is given to the Community pharmacist and GP

INTERACTIONS Interactions between feed and drugs

can be important. Always check with your pharmacist before administering any medication via a feeding tube. Where possible give dose during a break in the feeding regimen to minimise this.

Problem Drugs Phenytoin, Digoxin and

Carbamazepine: Blood levels may be affected by feeds, these should be checked regularly. It may be necessary to increase the dose.

Antacids: The metal ions in the

antacids bind to the protein in the feed and can block the tube. Consider using alternative drugs.

Penicillins: Feed may reduce the

absorption, a higher dose may be needed. If possible stop feed 1 hour before and 2 hours after administration.

Other antibiotics: Levels of antibiotics

such as ciprofloxacin, tetracyclines and rifampicin can be significantly reduced by feed.

Consider other alternatives or increase

doses. (This list is not exhaustive).

ADMINISTERING DRUGS VIA ENTERAL FEEDING TUBES A PRACTICAL GUIDE

STOP THE FEED Flush the tube with at least 30ml of water

Assemble medication and equipment needed e.g. syringes, pestle and mortar

Prepare each drug separately Never mix drugs unless instructed by a pharmacist

SOLUBLE TABLETS Dissolve in 10-15mls of water.

Administer down tube

LIQUIDS Shake well.

Viscous (thick) liquids-dilute With an equal

amount of water

immediately before

administration

Administer down tube.

TABLETS* Crush

uncoated and sugar

coated tablets using a pestle and

mortar or suitable device

CAPSULES* Open

capsules and tip powder

into medicines

pot

Do not crush: Enteric coated (EC) medicines Modified release (MR, SR, LA, XL) medicines Hormone preparations Cytotoxics Always seek advice

Mix with 10-15ml of water. Administer down the tube

Rinse tablet crusher/containers, and/or draw up water into the syringe used and flush this down tube.

This ensures that the whole dose is given.

If more than one medicine is to be administered- flush between drugs with at least 10ml of water to ensure that the drug is cleared from the tube

Flush the tube with at least 30ml of water following administration of last drug

RE-START THE FEED

http://www.bapen.org.uk/


PART 8

GUIDELINES FOR TROUBLE SHOOTING PROBLEMS ASSOCIATED WITH ENTERAL FEEDING TUBES

Note: Please refer to the Trust Procedure For The Insertion And Management Of Fine Bore Nasogastric Feeding Tubes in Adult Patients if using a fine bore NG feeding tube Or Procedure for the Management of Naso jejunal Feeding Tubes and Insertion of Self-propelling Naso jejunal Feeding Tubes in Adult Patients CG1166 if using a nasojejunal tube


CONTENTS

PAGE

Problem 1:

Tube blockage

66

Problem 2: Leaking tube/broken parts

67

Problem 3 (a): Leaking stoma site

67

Problem 3 (b): Acid burn to peristomal skin

67

Problem 4: Displaced tube

68

Problem 5: Over granulating tissue around stoma Site

69

Problem 6: Infected stoma site 69

References/ Bibliography

70


PROBLEM POSSIBLE CAUSES ACTION

1. Tube blockage (All types of tubes)

Inadequate flushing regimen Drug administration via tube

Using warm water and a 50ml catheter tip/female luer

lock purple enteral syringe, attempt to move the blockage with a push/pull technique on the plunger

While flushing, try to ‘milk’ the feeding tube between

thumb and forefinger to move the blockage Soda water or sodium bicarbonate (Dilution: ½

teaspoon in a glass of water) may be used instead of water alone with the above flushing technique

NB. Fruit juices and carbonated soft drinks (e.g.

Coke and lemonade) should not be used as they are likely to curdle the feed further (Pickering 2003, McClave & Neff 2006)

Contact the Nutrition Nurses if unable to unblock

who will review patient during working hours


PROBLEM

POSSIBLE CAUSES ACTION

2. Leaking tube/broken parts

Fractured tube Broken end/connector on tube

Contact Nutrition Nurses for advice – most broken connectors, clips and flanges can be replaced

3 a. Leaking stoma site (PEG or balloon retained gastrostomy tubes only) 3 b. Acid burn to peristomal skin or excoriation, secondary to leaking stoma site

External bumper incorrectly positioned

Delayed gastric emptying/obstruction or constipation

Poorly fitting tube Gastric acid coming in to contact

with skin Bowel contents from jejunostomy

tube coming in to contact with the skin

Check the position of the external bumper - pull gently on the feeding tube to ensure the internal bumper is against the stomach wall. Then, slide the external bumper down towards the abdomen. The external bumper should be no more than ½ cm away from the skin to allow slight movement. This helps to form a seal and prevent leakage.

If a dressing is being used it must be as thin as

possible (e.g. gauze and tape) and the flange should be tightened against it

Ensure patient is not constipated (this may increase

intra-gastric pressure leading to leakage from stoma site)

Protect the skin with a thin film of Cavilon™ No Sting

Barrier Film for severe excoriation a thicker barrier cream may be

necessary e.g. Sudocrem type creams Follow above steps (3 a) to correct leakage. CONTACT NUTRITION NURSES FOR ADVICE


PROBLEM

POSSIBLE CAUSES ACTION

4. Displaced tube (Jejunostomy, PEG, RIG and balloon retained gastrostomy tubes)

Confused patient pulling on tube Poor handling In the case of balloon retained

gastrostomy – balloon rupture

The stoma tract will begin to close within 1-2

hours. Therefore, it is critical that the tract is maintained. If discovered within this time -insert a similar sized Foley catheter or Corflo naso-gastric tube into the stoma to retain the site. Undue force should not be needed. However, after 1-2 hours it is unlikely that intubation will be successful.

N.B. A Medical Devices Alert (MDA/2004/006) stipulated that devices should only be used for the purpose for which they were intended i.e. a Foley catheter for urine drainage. However, in weighing up the risks to the patient of losing their feeding route against the potential risks of using a Foley catheter outside of license, it is acceptable for a Foley catheter to be used to maintain a stoma tract as a short term measure. It must not be used for feeding and should be changed to a replacement feeding tube as quickly as possible.

Contact the Nutrition Nurses or Gastroenterology

team immediately DO NOT FEED THROUGH A FOLEY CATHETER


PROBLEM

POSSIBLE CAUSES

ACTION

5. Over granulation of tissue around stoma site

External fixation device not correctly

positioned Poorly fitting tube

Ensure external fixation device is in the correct

position (see problem 3.a: ‘leaking stoma site’ for procedure)

the use of a double foam dressing may help to reduce the granuloma (Warriner et al 2012). If available the AMD antimicrobial foam dressing is impregnated with PHMB, which works as an antimicrobial agent and may help to reduce the incidence of infection associated with granuloma (Warriner et al 2012)

Contact Nutrition Nurses for advice

6. Infected stoma site (evidence of redness, swelling, discharge, pyrexia)

Poor hygiene when handling tube Bacterial translocation

Confirm presence of infection by taking a wound

swab

Treat with antibiotics/anti-fungal according to findings (to be prescribed)

Daily gauze/dry dressing until infection resolved.

The aim is to keep the site dry.

Ensure good hygiene practice.

Contact Nutrition Nurses if not improved


REFERENCES/ BIBLIOGRAPHY CREST (2004) Guidelines for the Management of Enteral Tube Feeding in Adults. Clinical Resource Efficiency Support Team. April 2004 Delegge M.H. (2006) Enteral Access in Home Care JPEN J Parenter Enteral Nutr January-February 2006 vol. 30 no. 1 suppl S13-S20 Leak K (2002) PEG Site Infections: A Novel use for Actisorb Silver 220. British Journal of Community Nursing. 7(6) 321-325

McClave S. & Neff R.L. (2006) Care and Long-Term Maintenance of Percutaneous Endoscopic Gastrostomy Tubes Journal of Parenteral and Enteral Nutrition, January – February 2006; vol. 30, 1 suppl: pp. S27-S38.

MDA/2204/006 Medical Devices Alert Pickering K. (2003) The Administration of Drugs via Enteral Feeding Tubes. Nursing Times Supplement, Nutrition. 99(46) Rollins H. (2000) Hypergranulation Tissue at Gastrostomy Sites. Journal of Wound Care. 9(3) 127-129 Warriner L & Spruce P (2012) Managing over granulation tissue around gastrostomy sites. British Journal of Nursing. 2012 Mar 8-21;21(5):S14-6, S18, S20 passim.

http://www.ncbi.nlm.nih.gov/pubmed/22489337


Part 9

GUIDELINES FOR CARING FOR A PATIENT WITH A NASAL LOOP/BRIDLE

Note: Please refer to the Trust Procedure For The Insertion And Management Of Fine Bore Nasogastric Feeding Tubes in Adult Patients if using a fine bore NG feeding tube or Procedure for the Management of Naso jejunal Feeding Tubes and Insertion of Self-propelling Naso jejunal Feeding Tubes in Adult Patients CG1166 if using a nasojejunal tube


CONTENTS PAGE Section 1 Introduction 73

Section 2 Indications 73

Section 3 Criteria in Confused Patients 73

Section 4 Contra-indications 74

Section 5 Nasal ‘Sloops’ 74

Section 6 Ordering the AMT Nasal Loop/Bridle 74

Section 7 Insertion 75

References/Bibliography 76

Appendices

Appendix 1 Nursing care of a patient 77 with a nasal loop/bridle

Appendix 2 Nursing care of a patient with a nasal 79 sloop inserted in theatre.


1.0 Introduction 1.1 A nasal loop/bridle is a retention device for securing naso gastric

feeding tubes by placing a thin piece of cotton tape around the back of the nasal septum and securing the tube to it. The AMT nasal bridle is a commercially available loop/bridle.

1.2 The AMT nasal bridle pack contains two probes with magnets on the

end of each and a thin piece of cotton tape attached to the end of one. A probe is inserted into each nostril until the magnets meet at the nasal septum. One probe is then withdrawn, pulling the cotton tape around the nasal septum. Once in place the patient has one end of the tape hanging from each nostril.

1.3 A nasogastric tube may then be inserted as described in the Trust

procedure for the Insertion and Management of Fine Bore Nasogastric feeding tubes. Once the naso-gastric tube is correctly placed it is then secured at the nostril to both ends of the cotton tape with a small clip.

Risks include

o Nasal trauma caused during insertion of the nasal bridle o Subsequent nasal/septal trauma due to undue pulling on the

NG/NJ tube or bridle tapes. o Septal erosion from bridle tapes o Nasal pressure ulceration if the tapes are too tight

2.0 Indications 2.1 For the confused patient, where there is documented evidence in the

patient’s notes of inadvertent displacement of the NG/NJ tube on more than 2 occasions in any 48 hour period.

2.2 Elective use to retain NG/NJ tubes which would be impossible to

replace or when replacement would be a high risk procedure. 2.3 For the patient with facial burns or skin allergies/conditions where it

may not be possible to secure the tube to the patient’s facial area. 2.4 For the patient being discharged home who requires an alternative

method to secure their NG/NJ tube 3.0 Criteria in confused patients.


3.1 Before considering a nasal loop/bridle for a confused patient there must be: Documented evidence that the patient lacks capacity and a best

interests decision has been made. Documented evidence that they have displaced their naso-gastric

tube themselves on at least 2 occasions in a 48 hour period. An indication that insertion of the nasal loop/bridle is in the patients

best interests 4.0 Contraindications

Patients with new facial fractures Patients with base of skull fractures Patients with an INR greater than 1.3 Patients who are competent but refuse to keep their naso-gastric

tubes in Lack of informed consent in a competent patient Where the risk of trauma caused by the nasal loop outweighs

the anticipated benefits.

5.0 Nasal 'Sloops' Other retention devices are sometimes fashioned and inserted in theatre when patients have undergone surgery. These are primarily used for securing a nasogastric drainage tube or feeding tube when the surgical team feel it is critical that these tubes are not displaced for a short time post operatively. Different materials may be used for this purpose such as plastic vascular tags. See appendix 2 for ongoing care of patients with a nasal 'sloop'. 6.0 Ordering the AMT Nasal Loop/Bridle 6.1 Where a patient is thought to require a nasal loop/bridle the referring

ward should order this from stores. This should be for a standard 8fg naso-gastric tube or 12fg nasogastric tube (mainly critical care areas) as the clips within the packs are made to fit specific size of tube. Ordering codes are available from the Nutrition Nurses.

The AMT nasal Bridle kit


7.0 Insertion 7.1 Patients who require a nasal loop/bridle must be referred to the

Nutrition Nurses who will assess the patient. If appropriate the Nutrition Nurses will then insert the nasal loop/bridle.

7.2 Medical staff may insert the AMT nasal loop/bridle if they are competent to do so. Insertion instructions are included with each nasal loop/bridle

7.3 Identified registered nursing staff may insert the AMT nasal loop/bridle on completion of the appropriate expanded practice competency document. See controlled document Ref: 269.2 Expanded Practice Protocol for the Insertion of Nasal Loops by Non-Medical Registered Practitioners (current version).


REFERENCES/BIBLIOGRAPHY Beavan J, Conroy SP, Harwood R, Gladman R. Leonardi-Bee J., Sach T, Bowling T, Sunman W & Gaynor C. (2010) Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Age and Ageing. Vol 39, issue 5 Gunn S.R., Early B.J., Zenati M.S.& Ochoa J.B. (2009) Use of a Nasal Bridle Prevents Accidental Nasoenteral Feeding Tube Removal JPEN J Parenter Enteral Nutr January-February 2009 vol. 33 no. 1 50-54 D. Johnston, L. O'Dell, M. Patrick, A, T. Cole and ,N. Cunliffe (2008). Outcome of patients fed via a nasogastric tube retained with a bridle loop: do bridle loops reduce the requirement for percutaneous endoscopic gastrostomy insertion and 30-day mortality?. Proceedings of the Nutrition Society, 67, E116 Power S., Smyth N, Duggan S, Roddy M & Feehan S. (2010) The Nasal Bridle: A useful approach to prevent the dislodgement of feeding tubes. The European e-Journal of Clinical Nutrition and Metabolism pages e73-e76


Appendix 1

NURSING CARE OF A PATIENT WITH A NASAL

LOOP/BRIDLE

ACTION RATIONALE

1.

Continue to confirm and re- confirm the position of the naso-gastric tube as described in the Trust procedure for the Insertion and Management of Fine Bore Nasogastric feeding tubes

The loop/bridle holds the tube in at the nostril but does not stop it being displaced from the stomach by vomiting, for example.

2.

Check the area around the clip at the nostril daily for any signs of pressure ulceration. Record the condition of the skin at each inspection. Inform the nutrition nurses immediately if there is any sign of pressure damage or soreness Record skin inspection on Skin Inspection and Assessment Chart (SIAT) and complete Datix

The clip may cause pressure to surrounding tissues if placed too tightly.

3.

Clean the nostrils daily and apply petroleum jelly if there is any soreness

Patient comfort.

4.

If the patient becomes distressed with the loop/bridle the loop may easily be removed by cutting one side of the tape and pulling gently on the nasogastric tube. Note: This will remove the nasogastric tube and loop at the same time.

Pulling excessively on the tube may cause trauma to the nasal septum

Patient comfort

5.

If it is not possible to confirm gastric placement of the naso – gastric tube according to described in the Trust procedure for the Insertion and Management of Fine Bore

The nutrition nurses may need to assist with re-positioning the loop/bridle and naso-gastric tube.

The clip on the loop/bridle may be opened to allow the


Nasogastric feeding tubes, contact the Nutrition Nurses for further advice. DO NOT use the naso gastric tube and do not remove the nasal loop.

nasogastric tube to be removed or repositioned without removing the whole loop/bridle device.

6.

If the naso-gastric tube becomes displaced, e.g. vomited into patient’s mouth, cut the loop to remove it.

To reduce patient distress


Appendix 2

NURSING CARE OF A PATIENT WITH A NASAL

'SLOOP' INSERTED IN THEATRE ACTION RATIONALE

1.

Continue to confirm the position of the tube according to the type of tube being secured. i.e. nasogastric for feeding or drainage or nasojejunal for feeding.

The sloop holds the tube in at the nostril but does not stop it being displaced by vomiting, for example.

2.

Check the area around the sloop at the nostril at least daily for any signs of pressure ulceration. Inform the medical team immediately if there is any sign of pressure damage or soreness Record skin inspection on Skin Inspection and Assessment Chart (SIAT). Complete Datix report. If the sloop appears tight inform the medical team immediately.

The sloop may cause pressure to surrounding tissues if placed too tightly.

Following insertion, the sloop may tighten while in situ. Informing the medical team of this will allow them to loosen it appropriately.

3.

Clean the nostrils daily and apply petroleum jelly if there is any soreness. Seek advice from tissue viability immediately if any soreness.

Patient comfort.

4.

If the patient becomes distressed with the sloop contact the medical team for advice regarding removal of the sloop.

Pulling excessively on the tube may cause trauma to the nasal septum

Patient comfort

5.

If the tube becomes displaced, e.g. vomited into patient’s mouth, contact the medical team immediately for advice

To reduce patient distress

6. The sloop should be removed as soon as the medical team deem it appropriate to do so. Depending on the material and method used to insert the

For patient comfort and to reduce the risk of pressure ulceration.


sloop nursing staff may be able to remove this. However, specific advice should be sought from the medical team.


Guideline Submission Guidelines reviewed by Jane Fletcher Nutrition Nurse Team Leader Hardip Malhi Nutrition Nurse Specialist Practice Development Team Nutrition and Hydration Steering Committee Infection Control Team Tissue Viability Team Parts 1 and 2 reviewed by Sharmalie Parkinson Nutrition and Dietetics Department Part 3 reviewed by Dr. Rob Jones Consultant Radiologist, CSL for Radiology Part 4 & 6 reviewed by Dr. Kate Kane Consultant Gastroenterologist, Nutrition Support Team Part 5 reviewed by Dr. Peter Riley Consultant Radiologist Part 8 reviewed by Anita Sangera Senior Pharmacist, Nutrition & Surgery Guidelines submitted to and approved by: Clinical Guidelines Group

controlled document - uhb

Documents